Professional Values of Undergraduate Students at a Nursing School in South Africa

Background Nursing schools play an important role in instilling nursing professional values in undergraduate nursing students and ensuring that they produce professional nurse graduates. Several studies in various countries have been conducted to describe the professional values held by nursing students, but this has not been explored in detail in South Africa. Aim The purpose of this study was to describe the professional values held by undergraduate degree students at a nursing school in South Africa. Methods A cross-sectional survey using a self-administered questionnaire was conducted. With a population of 1,233 undergraduate nursing students across four years in the degree programme at the nursing school, a sample of 294 was calculated as the representative (95% CI, 5% error, and 50% response distribution). The 26-item nurses professional values scale revision (NPVS-R) with five value dimensions was used to collect the data. Means, frequencies, and confidence intervals were used to describe the values and Mann–Whitney U tests and Kruskal–Wallis independent sample tests were used to compare the findings with the demographic characteristics. Results A total number of 245 respondents completed the questionnaire (response rate of 83.3%). Overall, the nurse professional value score was high (113.1 ± 13.1). The values of trust (4.46 ± 0.61), justice (4.39 ± 0.57), and caring (4.38 ± 0.55) were rated significantly higher than those of professionalism (4.23 ± 0.64) and activism (4.22 ± 0.57). First- and final-year students had significantly higher professional value scores. Conclusion The study results describe the professional values of undergraduate nursing students in the school and confirmed the importance of trust, justice, and caring as the key professional values in the South African setting. Clinical Relevance. Nursing education should embed and monitor nursing professional values in the curriculum. Instilling nursing professional values in undergraduate nurses during formal training programmes improves quality patient care and service delivery for clinical practice.


Introduction
Professional nursing values are the foundation of daily nursing care practice [1] and a corner stone in the selection and training of future nurses [2,3].To ensure quality ethical nursing care [4,5], these values serve as a guideline for their professional behavior [6].Tese values refect the integrity and professional identity of the nurse and reinforce performance in practice [6].As a new nursing student, it is important for students to start the process of professional values on entry as there is a relationship between the level of nurses' education and professional values [3,7].Tis was also supported by Arries [8], Bijani et al. [2], and Green [9], who suggest that the level of maturity of, i.e., junior and senior students, plays a role in the formation of professional values and was recommended for consideration for curriculum development [10,11].For new nursing students, professional values are rooted in personal values derived from their own culture and society [6] and are infuenced by many other factors such as education, attitude, religion, ethnicity, and culture [6,12].
Te responsibility of professional nursing programmes therefore is to embed and integrate professional values throughout the nursing curriculum and monitor the process of acquisition and practice of core values that occurs throughout the nurse's lifetime [7,[13][14][15].Te paradigm of nursing and nursing education emphasises the need for professional values such as trust and caring [12] and the importance of nurse graduates to be able to demonstrate these values in practice [9].
Embedding professional values in the curriculum requires the need to monitor professional values as an educational objective in nursing education.Research scholars have developed valid and reliable quantitative scales to measure nurses' professional values with the most utilized instrument being the nurses professional values scalerevised (NPVS-R), developed by Weis & Schank [16] and based on the 2001 American Nurses Association's Code of Ethics for Nurses.Te aim of this cross-sectional study was to describe the values held by undergraduate learner nurses in a school of nursing in South Africa, by using the nurses professional values scale which was developed by Weis and Schank [16].

Aim.
Te purpose of this study was to describe professional values held by undergraduate degree students at a nursing school in South Africa.

Design.
A cross-sectional survey using a selfadministered questionnaire was conducted with undergraduate student nurses at a university in the Western Cape in South Africa.

Study Population and Sampling.
Te study population had 1,233 nursing students registered for the undergraduate nursing program at a school of nursing at a university in the Western Cape in South Africa at the time of the survey.Using a 95% confdence level, a 5% margin of error, and a 50% response distribution, a sample of 294 was calculated, and using quota sampling per year level, all students were asked to participate.

Data Collection.
Tis study utilizes data from a larger data collection project on values-based leadership.Data were collected, with permissions from the university and the school of nursing, through face-to-face self-administered questionnaires from 29 th October 2019 to 5 th November 2019.Appointment schedules were drawn up to meet with year-level coordinators of six-year levels to arrange for an information session and a suitable timeslot in which the nature and purpose of the project were explained to the participants.Tey could then ask clarifying questions about the project.Written permission was obtained from participants who chose to voluntary participate in the project.Academic staf administered the questionnaire after class sessions.
Te inclusion criteria were that all students had to be registered in the legacy four-or fve-year degree program.Only 245 participants completed the questionnaires.Fortynine students of the calculated sample of 294 voluntarily decided not to partake in the study.

Instrument.
Te questionnaire included the validated nursing professional values scale (NPVS-R-5) (Weis & Schank, 2009).Te NPVS-R has previously been used in South Africa and comprises 26 items representing fve professional value dimensions, namely, justice (fve statements: 1, 2, 9, 14, and 15), trust (statements: 3, 12, and 13), professionalism (four statements: 5, 6, 7, and 8), caring (nine statements: 16, 17, 18, 20, 21, 22, 23, 24, and 25), and activism (fve statements : 4, 10, 11, 19, and 26).Te NPV-R scale used a 5-point Likert scale rating the importance of each individual statement with 1 rated as not important, 2 somewhat important, 3 important, 4 very important, and 5 most important.Te overall professional value score is out of 130 with a range of 26-130.More importance an individual ascribes to a value statement was refected in a higher total score, with scores below 43, between 43 and 86, and above 86 classifed as overall low, medium or moderate, and high importance of professional values, respectively [7].Studies conducted in Nigeria, Iran, Israel, Spain, and Turkey demonstrated scale reliability of the scale with a range of Cronbach Alphas from α � 0.81 to α � 0.96 [1,3,7,9,13].Tis was also confrmed in this study (α � 0.941).To further ensure reliability, a pretest study was conducted with 10 student nurses in their third year of study.No changes were made to the tool following the pretest, and the responses were included in the results.
2.6.Data Analysis.Data were analyzed using SPSS version 28.Demographics and scale dimensions were reported using descriptive statistics (frequency, percentage, mean, 95% confdence intervals, and standard deviation) and Mann-Whitney U and Kruskal-Wallis independent sample tests to compare scores across demographics.Te level of signifcance was set at p < 0.05.

Results
A total number of 245 respondents completed the questionnaire (a response rate of 83.3%).Te respondents had an average age of 22.2 (±3.6) years, and most of the respondents were female (210, 85.7%).Te respondents were evenly distributed across year levels with 62 (25.3%) in year 1, 62 (25.3%) in year 2, 62 (25.3%) in year 3, and 58 (23.7%) in year 4 (Table 1).Respondents reported having been in the school on average for 2.7 ±1.3 years, ranging from 1 to 7 years.
Te most important values from the respondents' perspective were "Maintaining confdentiality of patients" (4.59 ± 0.71), "Safeguarding patients' right to privacy" (4.58 ± 0.68), and "Protect moral and legal rights of patients" (4.53 ± 0.69) from the caring dimension, "Promote equitable access to health care" (4.53 ± 0.71) from the trust dimension, and "Maintain competency in area of practice" (4.53 ± 0.74) from the justice dimension (Table 2).Te least important rated values were "Participate in peer review" (3.96 ± 0.90) from the professional dimension, "Participate in public policy decisions afecting distribution of resources" (3.88 ± 0.92) from the activism dimension, and "Refuse to participate in care if in ethical opposition to own professional values" (3.82 ± 1.16) from the caring dimension.

Discussion
Tis current study has shown high ratings of the importance of professional values by the nursing student respondents (113.1 ± 13.1) in this setting, similar to other studies that reported high scores for nursing students, as well as nurses' (who were at diferent levels of education and generations) professional values, using the NPVS-R [7][8][9].Tis suggests that according to this scale, undergraduate nursing students in this school have achieved success in embedding professional values in nursing during the nurse training programme.Tis study also confrms another older South African study (Weis & Schank, 2009) who found high overall levels of professional values.
Te most important value was trust, with the statement "Promote equitable access to health care," ranked third amongst all the value statements, with a mean score of 4.53 (0.71).A reason for this high score could be attributed to the context of the study where there are still disparities between socioeconomic groups in South Africa [17], and many respondents come from low socioeconomic communities with poor access to health care.Access to quality services in South Africa has remained low despite many eforts and approaches by African countries to equalise health care [18].
Within the value dimension of caring, the highest ranked ratings in the scale were for the following: "Maintain confdentiality of patients," "Safeguard patients" right to privacy," and "Protect moral and legal rights of patients" which was rated 4 th highest.Tese fndings were congruent with the fndings of a study conducted in Iran which compared the professional values of nursing students, nurses, and nursing educators and found overall mean scores for all within the range of relatively important or important.Similarly, from the student nurse's perspective in Iran, statements which relate to caring such as "Maintain confdentiality of patients" and "Protect moral and legal rights of patients" had the highest importance ratings for nursing students [2].
Similar to other studies by Chikeme [3] and Poorchangizi et al. [7], the following statements were rated as less important in the current study: "Recognizing role of professional nursing associations in shaping healthcare policy" (ranked 20 th ), "Engaging in ongoing self-evaluation" (ranked 21 st ), "Participating in nursing research/implementing research fndings appropriate to practice" (ranked 22 nd ), and "Participating in peer review" (ranked 24 th ).Tough similar, the respondents in the Poorchangizi et al. [12] study ranked "Recognizing role of professional nursing associations in shaping healthcare policy" 24 th , "Engaging in ongoing self-evaluation" 17 th , "Participating in nursing research/implementing research fndings appropriate to practice" 23 rd , and "Participating in peer review" 25 th , which could be attributed to certain factors in their settings such as educational semester, low motivation, insufcient afrmation, and low encouragement by nursing educators.Although students in this study are being taught about the importance of participating in peer review during their course of training for quality assurance purposes, no actual opportunities exist in undergraduate progammes where students can actively engage and involve themselves in peerreview activities.However, nurse educators do ensure the presence of the "student voice" during accreditation processes by the regulatory body of South Africa and opportunities where there are formal disciplinary hearings and curriculum reform at the institution of higher learning.However, not all students get the opportunity to be selected when these opportunities arise, and therefore, the majority of students might regard this item "Participating in peer review" as least important amongst the values because of not knowing what it actually entails.
A major concern was the low ranking (26 th ) of importance of the statement "Refusing to participate in care if in ethical opposition to own professional values," in contrast with Poorchangizi et al. [12], whose respondents ranked this  Nursing Research and Practice statement more important at 13 th amongst the value statements.Tis statement is from the caring value dimension and is central to ethical decision-making in practice [7].Our fnding may relate to the diverse context in South Africa with most of the student population having varied value orientations, but this would have to be investigated further.Another reason for the low ranking of this value statement could also be due to students not being exposed enough to real-life encounters of an ethical nature in practice, but this also requires more research.A further concern is the low ranking of the statement "Participating in public policy decisions afecting distribution of resources" which ranked 25 th in this study and 26 th in the study by Poorchangizi et al. [12].Health and public policy are essential elements of professional obligations of nurses [19].Also, the American Nurses Association's [20] nursing Code of Ethics state that nurses have a responsibility to participate in political processes and advocate for their patients [21].Tough respondents rated "Acting as a patient advocate" as an important value under the caring dimension at 11 th , "Participating in public policy decisions afecting distribution of resources" was ranked 25 th which is considered as the least important, highlighting a diference of a belief and translating this value into practice amongst the respondents.Tese values are taught in the nursing school, but being a student may provide limited ability to engage in health and public policy activities [22].In addition, the current programme may not adequately equip students with the analytic, communication, and leadership skills to translate this into practice, but this should be further investigated [12].Tis could be the same reason why students in this study scored the statement low, as not enough emphasis is placed on active involvement and engagement in public policy at student level.Also, in the current study, opportunities at policy discussion level are almost nonexistent in the programme and should be further explored by nurse educators to give students more exposure to boost their leadership skills.
Tere was no signifcant diference found in this study between professional values and gender (p � 0.102).Nearly, all respondents rated professional values as very important (197 (80.4%)) and only 11 (4.5%) as medium important.Te results of the current study were similar to those of a study that was conducted in Pakistan in 2018, which showed that male and female respondents paid equal attention to professional values [5].However, the study confrmed previous papers which suggested that the level of education infuenced the integration of values [10,11,13], with diferences due to demographics related to academic levels of study.In all four-year levels, the respondents had high overall scores for professional values, but frst-and fnal or fourth-year level students recorded signifcantly higher ratings in professional values than students in their second and third years (112.8 and 109.6,respectively, K � 11.1, p � 0.025), though they might not consider each value and its corresponding statements as equally important [23].Te fndings were in line with a study in Turkey [24] which indicated that the academic year had an efect on the professional values of nursing students, and [9] a study in Israel with novice (frst year), advanced (third year), and senior (fourth year) students also found statistically signifcant diferences between these groups.Te high ratings in the frst year in the current study were consistent with fndings by Bleda et al. [13], who found that nursing students rated professional values as highly important when they enter the nursing profession because of some students having inadequate clinical experience to accurately rank the statements.In our study, the high scores of frst-year respondents could relate to high levels of preexisting values which then further translate into professional values towards the end of their training [13].
Another reason could also be that South African nursing students come from diferent cultural backgrounds and enter the university with a set of diverse values that could infuence how each student assigned meaning to the importance of professional values and how they scored the statements.Te fnal-year respondents are also more mature students, preparing for practice as new graduates, which may refect the preparation for practice [13].Furthermore, the fnal-year respondents in this current study also have a formal professional practice module in their fnal year of study which exposes them to further growth and development of these values as they take on more responsibilities as senior students.Tis professional maturity is linked to chronological maturity as these students have been exposed to the need to make independent judgments in their professional and personal lives [8,9].Bijani et al. [2] also found a similar pattern with higher academic levels being associated with higher scores for professional values.

Limitations.
Tere are some limitations in this study.First, respondents were from one university in the Western Cape Province of South Africa only, and though it confrmed 2009 South Africa study's fndings, caution should be taken in generalizing these fndings to undergraduate nursing students in South Africa.Furthermore, because of the diverse nature of the study population, religion, cultural background, language, and ethnic origin may infuence the development of professional values but are not explored in terms of their association with nurses' professional values in this study.Te study did not explore the reasons for the ratings, and further studies are needed to explore the factors that infuenced the low ratings for professionalism and activism values.

Conclusion
Professional values in nursing students are central to their training as these values would determine quality patient care service delivery and guide new graduates in their ethical decision-making while in nursing practice.Tis study showed that the respondents rated professional values highly and that this may be due to the selection process of students entering the programme and the process of embedding professional values in the nursing curriculum.

Table 2 :
Value dimensions and statements.